Provider Demographics
NPI:1558483461
Name:GOMEZ REYNOSO, MARCOS A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCOS
Middle Name:A
Last Name:GOMEZ REYNOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-0171
Mailing Address - Country:US
Mailing Address - Phone:787-922-7687
Mailing Address - Fax:
Practice Address - Street 1:AZALEA 2048, LEVITTOWN
Practice Address - Street 2:
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:787-922-7687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11079208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice